Provider Demographics
NPI:1265676670
Name:VIRGINIA BEACH METHADONE CLINIC
Entity Type:Organization
Organization Name:VIRGINIA BEACH METHADONE CLINIC
Other - Org Name:SELLATI & CO., INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-677-1757
Mailing Address - Street 1:1728 VIRGINIA BEACH BLVD
Mailing Address - Street 2:STE 113
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-4533
Mailing Address - Country:US
Mailing Address - Phone:757-437-0411
Mailing Address - Fax:757-437-5846
Practice Address - Street 1:1728 VIRGINIA BEACH BLVD
Practice Address - Street 2:STE 113
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4533
Practice Address - Country:US
Practice Address - Phone:757-437-0411
Practice Address - Fax:757-437-5846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA089261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone